Anesthesia and analgesia
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Anesthesia and analgesia · Feb 2002
Randomized Controlled Trial Clinical TrialThe timing of intravenous crystalloid administration and incidence of cardiovascular side effects during spinal anesthesia: the results from a randomized controlled trial.
We conducted a randomized clinical trial to evaluate the efficacy of crystalloids in preventing spinal-induced hypotension (SIH) and cardiovascular side effects (CVSE) in a group of surgical patients. Participants were assigned to receive lactated Ringer's solution at 1-2 mL/min (Placebo group, n = 142); lactated Ringer's at 20 mL/kg starting 20 min before spinal block (n = 130); or lactated Ringer's at 20 mL/kg starting at the time of spinal block (n = 132). SIH was defined as a decrease of > or = 30% in baseline systolic blood pressure, and CVSE as SIH plus nausea, vomiting, or faintness requiring treatment. The incidence of SIH was similar in all treatment groups. Compared to placebo, crystalloid administration at the time of spinal block resulted in a significant reduction in the proportion of patients developing CVSE from 9.9% to 2.3%. The corresponding relative proportion was 0.23 (95% confidence interval, 0.07-0.78; P = 0.019), and one additional case of CVSE was avoided for each 13 patients receiving crystalloids at the time of spinal block instead of placebo. Administration of crystalloids at the time of spinal block seems to be effective because it provides additional intravascular fluids during the period of highest risk of CVSE after spinal anesthesia. ⋯ Crystalloids are frequently administered to nonobstetric patients minutes before spinal anesthesia to prevent cardiovascular side effects (CVSE). This randomized controlled trial shows that although crystalloids administered before spinal block result in no clinical benefit, they significantly reduce the risk of CVSE when administered at the time of spinal block.
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Anesthesia and analgesia · Feb 2002
Randomized Controlled Trial Multicenter Study Clinical TrialThe efficacy and safety of three concentrations of levobupivacaine administered as a continuous epidural infusion in patients undergoing orthopedic surgery.
We evaluated the efficacy and safety of three concentrations of levobupivacaine infused epidurally as analgesia for patients undergoing orthopedic procedures. Patients undergoing elective hip or knee joint replacement were enrolled in the study (n = 105). Sensory blockade was established preoperatively with 10-15 mL of 0.75% levobupivacaine. Patients were then randomized to receive 0.0625%, 0.125%, or 0.25% levobupivacaine as a continuous epidural infusion at 6 mL/h for 24 h. IV morphine patient-controlled analgesia was given as rescue analgesia, and time to first request for analgesia and total dose of morphine consumed were recorded. Sensory blockade, motor blockade, visual analog scale pain score, and cardiovascular variables were also recorded at regular intervals postoperatively. Ninety-one patients were included in the primary intent-to-treat analysis. Total normalized dose of morphine, number of patient-controlled analgesia requests, and overall postoperative visual analog scale pain scores were significantly lower for the 0.25% group compared with the other two groups, and the time to first request for rescue analgesia was longer. There was no significant difference between the 0.125% and 0.25% groups in terms of maximum motor blockade achieved and time to minimal motor blockade. Safety data were equivalent among the three groups. We conclude that levobupivacaine as a continuous epidural infusion provided adequate postoperative analgesia and that the 0.25% concentration provided significantly longer analgesia than 0.125% or 0.0625% levobupivacaine without any significant increase in detectable motor blockade relative to the 0.125% group. ⋯ Postoperative epidural infusion of levobupivacaine can provide safe and effective analgesia for patients having hip or knee joint replacement. Of the three concentrations we infused at a constant rate, 0.25% provided significantly better pain relief.
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Anesthesia and analgesia · Feb 2002
Randomized Controlled Trial Comparative Study Clinical TrialRopivacaine undergoes slower systemic absorption from the caudal epidural space in children than bupivacaine.
We compared the systemic absorption of ropivacaine and bupivacaine after caudal epidural administration in children. Twenty ASA physical status I or II children aged 1-7 yr undergoing elective hypospadias repair were randomized after the induction of general anesthesia to receive a single caudal epidural injection of 2 mg/kg of either ropivacaine 0.2% (R) or bupivacaine 0.2% (B) in a double-blinded fashion. Peripheral venous blood samples (1 mL) were obtained before and 1, 5, 10, 15, 20, 30, 40, 50, 60, 70, 80, 90, and 120 min after the caudal injection. The total R and B concentration was measured in plasma by using high-performance liquid chromatography. All blocks were successful, and there were no complications. The peak plasma concentration (mean +/- SD) (R = 0.67 +/- 0.16 and B = 0.73 +/- 0.23 microg/mL) and the area under the plasma concentration curve (R = 61.9 +/- 20.6 and B = 62.7 +/- 18.2 microg x mL(-1) x min(-1)) were comparable between the two study groups. The median (range) time to attain peak plasma concentration was significantly slower in children who received ropivacaine (R = 65 [10-120] min and B = 20 [15-50] min, P < 0.05). We conclude that ropivacaine undergoes slower systemic absorption from the caudal epidural space in children than does bupivacaine. ⋯ We compared the systemic absorption of ropivacaine (0.2%) and bupivacaine (0.2%) after caudal epidural injection of 2 mg/kg in children aged 1-7 yr. Our results show that ropivacaine undergoes slower systemic absorption from the caudal epidural space in children than does bupivacaine.
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Anesthesia and analgesia · Feb 2002
Randomized Controlled Trial Comparative Study Clinical TrialParavertebral blockade for minor breast surgery.
Paravertebral blockade (PVB) has been advocated as a useful technique for breast surgery. We prospectively compared the efficacy of PVB via a catheter technique with the efficacy of general anesthesia (GA) for minor breast surgery. Thirty patients were randomized into two groups to receive either PVB or GA. Variables of efficacy were postoperative pain measured on a visual analog scale, postoperative nausea and vomiting (PONV), recovery time, and patient satisfaction. Postoperative visual analog scale scores in the PVB group were significantly lower in the early postoperative period (maximum, 12 vs 45 mm; P < 0.01). In both groups, PONV was nearly absent. There was no difference in recovery time. Patient satisfaction was better in the PVB group (2.8 vs 2.3; scale, 0-3; P < 0.01). There was one inadvertent epidural block and one inadvertent pleural puncture in the PVB group. Although PVB resulted in better postoperative pain relief, the advantages over GA were marginal in this patient group because postoperative pain was relatively mild and the incidence of PONV was small. Considering that the technique has a certain complication rate, we conclude that at present the risk/benefit ratio of PVB does not favor routine use for minor breast surgery. ⋯ This study confirms the previously reported superior pain relief after paravertebral blockade (PVB) for breast surgery. However, considering the relatively mild postoperative pain and therefore the limited advantage of PVB for these patients, the risk/benefit ratio does not favor the routine use of PVB for minor breast surgery.
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Anesthesia and analgesia · Feb 2002
Randomized Controlled Trial Comparative Study Clinical TrialSmall-dose selective spinal anesthesia for short-duration outpatient laparoscopy: recovery characteristics compared with desflurane anesthesia.
We conducted a randomized controlled trial to compare the recovery characteristics of selective spinal anesthesia (SSA) and desflurane anesthesia (DES) in outpatient gynecological laparoscopy. Twenty ASA physical status I patients undergoing gynecological laparoscopy were randomized to receive either SSA with lidocaine 10 mg + sufentanil 10 microg or general anesthesia with DES and N(2)O. Intraoperative conditions, recovery times, postanesthesia recovery scores, and postoperative outcomes were recorded. Intraoperative conditions were comparable in both groups. All patients in the SSA group were awake and oriented at the end of surgery, whereas patients in the DES group required 7 +/- 2 min for extubation and orientation. SSA patients had a significantly shorter time to straight leg raising (3 +/- 1 min versus 9 +/- 4 min; P < 0.0001) and to ambulation (3 +/- 0.9 min versus 59 +/- 16 min; P < 0.0001) compared with the DES group. SSA patients had significantly less postoperative pain than DES patients (P < 0.05). We concluded that SSA was an effective alternative to DES for outpatient gynecological laparoscopy. ⋯ This study compared the use of a desflurane general anesthetic to a small-dose spinal anesthetic in ambulatory gynecological laparoscopy. Using the spinal technique, patients can walk from the operating room table to a stretcher on completion of surgery. Their recovery time was similar to that of the desflurane group.